Excision of Endometriosis

What is excision of endometriosis and why is it different? Let’s take a step back and look at the history of surgical approaches to endometriosis.

Way back in the dark ages before laparoscopy and lasers, all surgery consisted of cutting a patient open and removing their disease. This approach has been used to treat endometriosis since the 1800s, and a prominent gynecologic surgeon, Dr. Joe Meigs wrote in the 1950s about excision: “…recurrence is not frequent, and cure…by conservative surgery is usual.” From the turn of the century until the 1970s, endometriosis was much less frequently diagnosed than it is now, but more likely to be removed when it was found.

Then a wonderful thing happened in the 70s and 80s- no, not disco, Laparoscopy! This radical new approach allowed surgeons to operate on structures deep inside the body using only tiny little holes through which a telescope and operating instruments were placed. Laparoscopy allowed for better visualization of the deepest part of the pelvis where endometriosis likes to live- behind the uterus in the culdesac which can be very hard to see in open surgery. Along with the development of vision through tiny little incisions came new instruments such as lasers and new techniques such as ablation of endometriosis. Since surgery was less invasive, it became less risky to perform, and the concept of a diagnostic laparoscopy was born. This allowed doctors to recognize endometriosis more, but the methods they were using to treat it hadn’t yet been verified. Early studies of endo and laparoscopy were mostly focused on infertility rather than pain relief, and even though no studies showed significant long-term pain relief, ablation (burning) of lesion using either cautery (electricity) or laser (light energy) became standard treatment, alongside Danazol and later Lupron. Despite little to no evidence to justify these methods, in my residency in the early 1990s, laparoscopy with ablation of endo followed by Lupron was taught as “THE way” to treat endometriosis. Subsequent to it’s acceptance as standard of care, some studies were done to assess pain relief after ablation surgery. In 2001, Jones, et.al. looked at 6 year followup of laser ablation for stage 1 and 2 disease and found that 74% of patients had recurrence of pain at an average of 20 months. In 2005, Wright, et al, studied stage I disease comparing ablation with excision , and at 6 months postop, the results were equivalent. There are no studies looking at ablation for stage IV disease.

So, two generations of gynecologists have been taught how to treat endometriosis based on first no data, then on data that shows that the standard techniques don’t work well. This is why most GYNs say that endo can’t be cured, that it always comes back, and that when it does recur the only thing to do is a hysterectomy and oophorectomy (removing ovaries, inducing permanent menopause).

My oh my what a predicament for women with pelvic pain….

Fortunately, there is another option. Excision of endometriosis is the technique by which the disease is removed by cutting it out. There are many ways to accomplish this- some use lasers, some use cautery, some use robots – the tools that a surgeon uses to facilitate excision really don’t matter, but what does is that all disease is removed entirely no matter where it is. Excision allows us to remove endometriosis that lies over the ureters and on the bowel – places where it’s not safe to just burn the disease. Excision also lets us remove the disease and leave in the reproductive organs to both preserve fertility and avoid castration of young women that can cause a lifetime of hot flashes, bone loss, sexual dysfunction, vaginal atrophy, memory loss…. I could go on and on.

Excision has been studied quite extensively, and many different studies from around the world have shown very consistent results. Redwine published his outcomes in 1991 after laparoscopic excision of endometriosis where he followed those patients for up to 7 years postop. About half had no further pain and no reasons for subsequent surgery, and the other half required another surgery for various indications- pain, bleeding, masses, etc. He showed a 57% cure rate in reoperated patients, and a 19% incidence of recurrence or persistence among all patients who underwent excision (this assumes no recurrences in the pain-free patients who didn’t have another surgery). Several other studies showed very similar results (Wheeler, Malinak; Varol et al). Recently there was a study published by Heaney in 2010 that randomized patients to excision vs ablation. Despite several problems with the study (not enough patients, non-expert surgeons- residents- performing the excision, higher stage patients in the excision group), there were trends towards much better pain relief in the excision group. They looked at decreases in pain scores at 1 and 5 years postop in various categories, and in nearly all areas (back pain, rectal and defecation pain, nausea, bloating, dyspareunia) the excision group did much better. Since they designed the study for 75 patients in each group but wound up with only 50, it was underpowered which means that even though there were clear differences between the groups in terms of outcomes, they didn’t reach statistical significance. I believe that if this study was redone with the full numbers of patients to power it correctly it would have shown a “significant” difference, thus carrying more weight in the scientific community. To me it still shows that excision is better.

So, to summarize, the published data show a 19% chance of persistent or recurrent endometriosis after excision surgery by an expert, and a nearly 60% chance of a surgically proven cure, meaning that at a subsequent surgery no endometriosis was found. There is a big difference in the ability to remove all endometriosis between a surgeon who does 15-25 major endometriosis excision cases a month and those who dabble in it, so these results will not translate to all surgeries that are called excision. To be clear, there are many gynecologists who mean well and truly believe that excision of endometriosis is the best way to treat the disease, and they can often do a good job on superficial disease and endometriomas. The challenge is that deep disease is technically much more difficult to remove and requires significantly more skill by the surgeon, which is why it is very important who actually does your surgery. This is probably the main reason why there are so few expert excision surgeons, along with the fact that there is no national organization championing the need for it, or sponsoring fellowship training for excision.

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Testimonials

I had really bad periods and PMS when I first started my period when I was 13 years old and then the pain got worse during my late teens, early 20’s. I would go to the doctor multiple times saying I have really severe cramps … "I had really bad periods"

Julia

Dr. Mosbrucker gave me my life back! I started having symptoms of Endometriosis at age 14. I had doctors throw me on birth control and leave it at that. As I got older it got worse and worse. In high school I was missing classes … "Dr. Mosbrucker gave me my"

Nancy

Where to start? I came from out of state (Oregon) and Dr. Mosbrucker and her staff were very easy to communicate with. Not only did Dr.Mosbrucker expertly excise my Endometriosis, she also referred me to a Pelvic Physical Therapist in my area who diagnosed and … "Where to start? I came"

Marisa

I was so lucky to find Dr. Mosbrucker. Other doctors made me feel like I was exaggerating about my endometriosis pain, that it was somehow my fault, or that the pain was something I just had to accept and live with. Dr. Mosbrucker always took … ""

Jen

I have/had stage IV endometriosis, with extensive disease on the bowel. I was in chronic pain and discomfort. After years of searching for a surgeon who believes in surgical excision of endometriosis, I found Dr. Mosbrucker. Even though I live 3 hours away, I happily … ""

Heidi

It is very difficult to truly describe the life-transforming role Dr. Mosbrucker and her team played in my life over the past 6 years. When I met her, I was without hope – she was my last chance for any kind of peace in my … ""

Susan

I am not a patient of Dr Mosbruckers, however I am an endometriosis patient advocate. I first met her when she was in Bend Oregon with Dr Redwine. I was immediately taken with her enthusiasm for adding these advanced excision techniques to her already substantial … ""

Nancy

Dr. Mosbrucker did the right surgery for my endometriosis. She is a true expert in Endometriosis and pelvic floor surgery. She gave me my life back when I had already resigned to live a life imprisoned in my body until I die. I found her … ""

Nalyne

May 2013, we brought our 19 year old daughter from Ontario Canada to be diagnosed and treated for endo with Dr Mosbrucker in Washington state. The relief upon meeting with a Doctor, who not only understands the significant pain with the disease but is an … ""

Debbie

I have dealt with endometriosis from a very young age which caused extensive damage, unfortunately I was led to believe a hysterectomy with ovaries removed would be “the cure” this did not cure me but instead caused more damage and made life so much more … ""

Tina

I had been suffering with endometriosis for 5 years and had been through 5 failed surgeries before finally sending my records to Dr Mosbrucker for review. I was a bit worried about travelling so far from home for surgery because some of my first surgeons … ""

Michelle

As an RN I have worked with many surgeons and other healthcare providers. Being on the other side as a patient, is a difficult position to be in. However, Dr. Mosbrucker has been one of the most compassionate surgeons I have encountered. She is obviously … ""

Nathalie

When I met Dr. Mosbrucker I felt like a broken woman. I was physically, emotionally, spiritually, and quickly becoming financially broken from my ongoing battle with pelvic pain. For nearly twenty years I had been reporting my symptoms to health care providers. I had been … ""

Beth

As one of Dr Mosbrucker’s pts I wanted to leave a testimonial for her website. I’m looking forward to her opening. And can’t wait to get an apt! Endometriosis is an awful disease that unfortunately goes undetected for years. Meanwhile the women with endo suffer … ""